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HomeMy WebLinkAbout14058 (17) � � � � �� _ CITY OF DIAMOND BAR �� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERYICES ( \ ` / „ 21660 E.Copley Drive Suite 190 / � �'.�'. PRESS � (909)860-3195 Fax(909)861-3117 �' •��'��� BUILDING PERMIT APPLICATION FIRMLY � ADDR'ESS I � �� �� S`�L APPLICATIOI�i��,�����_���PERMIT %���� P!C DA7E / I �NUMBER # � ISSUE TYPE OCC APN LOT TRACT DATE CQNST. GROUP p OWNER 1 oa � L " ADDRES O �, �L ZONING SETBACKS � CI1Y ZiP TEL._ ! REART RW n-- APPLlCANT TEL._ SIDElSIDE STREET RW_,_______ [.I� � CONTRACTOR J r.l C� ' _ S{DE __ ❑_ p� ADDRESS p,pppSED USE`�C7�i��� �(�S • S � CITY [� ZIP��EL._,3 2. f _ u � QARCWENGI � � z DESIGNER, NO.DWEL. NO. NO. � ADDRESS UNITS� STORIES � BEDROOMS � CITY ZIP TEL. � — DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANAIUATION � m OWNER•6UILDER DECLARATION SFq/ADD/REM � p I HENEB�AFFIRM UNDER PENALTY OF PERIURY THAT I AM EXEMAi FqOM THE CON7flACTOqS LI- Gafage/Carport LLI CENSEUWFORTHEFOLLOWINGREA50N(SEC.7031.5BUSINESSPNDPROFESSIONSCODE'ANYCITYOR (n , CJ COUNTYYIHICMHEWIRESAPEflMRTOfANSTPUCT,ALTFR,IMVFlOVE,�EMOLISH,ORREPAIRANVSTRUC- W Pai10/DeCk Z TURE,PRION TO ITS ISSUANCE,hL50 REOUIRES iME APPLICANT FOfl SULH 7EflM1T TO FIIE A SIGNED � S7ATEMENT TiAT HE OR SHE IS LICENSED PURSUAN7 TO THE PHOVISK7NS OF THE CONTRACTORS LI- � CENSE IAW(CMAPTEfl B�COMMENCINa W17HSECTION 7000)OF DIVISION 30F THE BUSINE3S AND PR0- U' PooUSpa FESSIONSCODE)OR7FNTHEORSHEISE%EMPTTHEflEFROMANDTHF.BA515FORTHEAl1,EGEUEXEMP- (� J.^ V. TIOq.PNYVIOLRTbNOFSECTION7U37.58VANYAPPLICANTFOqAPEPMITSU&IECTSTHEpVPLICANTTO z Re-Roof ZW� � ACIVILPENIILTYOFNOTMORETHANFIVEHUNDFEODOLLARS(E5W).�: � f11,A50WNEROFTHEPROPERTY.OflMYEMPLOYEESWITHWAGE5A5TMEIRbOLEWMPENSATION, � COf11ti10fCi81 ' VALL DO TNE WORK.l�NO THE STRUCTURE�S NOT INTEN�ED Oq OFFERED FOR SALE(5EC.7oea,BUSI• J NESS AND PFqFE&S�ONS CODE:h1E CONTflACTORS LICENSE UW UOES NOT APPLY TO AN OWNER OF y� PROPERTYWFiOBUIIDSORIMPROVESTHEREIXJ,ANDWHO00ES5UCHWORNHIMSELFOHHERSELFOR . � � 7NflIXIGHHI$ORHER06lME�lALOVEES,PROVIDEDTNATSUCHIMPflOVEMENTSAqENOTINTEN�EDOR CD �. ,OFFEREpWR5P1EIF,HOWEYERiNEBUILDWGORIMPpOVEMENTISSOtOWITY4NONEYEAROFCOMPLE- Z TION.T1E OWNEN-BUIIDER WILL HAVE THE BUR�EN OF PROVI�G THAT HE OR 3HE DID NOT BUIID OH � W�, IMPfpVEWRTMEPURPOSEOF;ALE)� Cl I,AS OWNER OFTHE PROPERTV,AM FXCLUSNEI.V CONTflACTING WITH I.ICENSED WNTRACTORS ([- TO CONSTHUCT THE VHOJECT(SEC.70aa,BUS:NE55 ANO PROFESSIONS CODE:THE fANiRACTORSIJ- VdIUeSIWIR'� __ _____ADJ.AREA_____ __ _ _ w CENSEIAWDOE5N07APPLVTORNOWNEHOFAPROPERTVWH09UIL�SOqIMYIiOVESTMEREON,AND �' VAIOCONTRACTSFORSIICMFRQIECTSWITHACANTRACTOR(S)LIGENSEDPURSUMITTOTHECONTqAG � QUANTITY DESCRIPTION FEE YORS UCENSE LAWJ. J �i O I AM EXEMPTUNDEH SEC._..__'_' __"'_'B.8 P.G FOq THIS R�SON Q �� -'- "'_""_ U � tL: UATE� OWM1ER'_'...__'_' "'_—_"'_'� V �. Z' ' - W V F> LICENSED CONTRACTORS DECLARAI"ION w �� I HEREBYAFFIRM UN�ER VENALTY OF PERIUftY THAT I AM LICENSED UN�[R P70VISIONS OF CHAVTER �e � �; e(COMMENCING WITH SEGTIOM 700DJ OF UIVISION]OF 7NE BUSINESSANO PROFESSIO�S l:U�f,AND z _ ���, MY LICENBE IS IN FULL FOflCEAND EFFECT. �--y � �; L�CENSE CLAS5 ��- Lic.N0.. J � ��_ _ j - - Ij. V' DATE ����9_._ CONTRACTOR_ _ a W �� �. �,i,.���'� Wp I�RS'CUMPENSATION OECLARATION Q — � �r7 U IHEflEBVAFFiH1AUND��PENAL7VOFPERIURVONEOFTHEFOLLOWiNGDECLAHlTIONS: Z �� �' � � - �,� _IHAVE)NDW�LlMA1NTAINACtRTtFICA7EOFCANSENTTOSEI.F�INSUREFORWONKE115' '- GOM:EI3SATtOY,AS PROVIOEO yY SECTION 37ao OF THE LABOH CODE,FOH TME PERFORMANCE W OFTHE WOFiK FOR WHidi THIS P[FiMIT IS ISSUEU � � W I HAVEAND WIU.MAIMAIN WOHK[FlS'COMPENSATION INSURANCE.A5 REQUIRF.D k3Y SECTION ""') 1, j Q 370o OF TNE LABOfl CODF,FOFi THE PERFORMANCE OF THE WORK FOR W4ICH TH�S PERMIT IS �) [ � ISSUED.MVWORKEHS^,Cf}�VENSATIONINSUANCECAHRIEHANO UCYNUMt3[RARE: CONSTRUCTION _.._ ___ ..________ � __/a�'>�� ' � PLAN REVIEW • � . . .... .-----�- ��� CAFi IER,�_ .. ' i '_ .y. _ _ ____ "- '. _"_ Z c �wuueEA __ _ - ELECTRIC _._.._ _ _. ____ � � � `..,....� --'-- 0 �crqrrr�mnoreEmnw�ooFn�aer+narswaoriErawn�000�uascs+aa�w+�Essy PWMBING ---.... - --.. """ Z'- `� CERTIFYTHATINTHEPERFOFMf�\CEUFTH[V20RKFORWHICHTHISPERMITISISSl:EO,I MECHANICAL "�""' (� _, SHAIL NOT EMP�OYANY PERSON IN ANY MANNEF SOAS TO 9ECOML SUIiJECTTO THE .�- ' '������ ' „ (n,. MORKERS'COMPEN5AT10NlAW5OFCALIFORNIA,ANCACREETMATIFI3HOlIL[lB[COME �NSPECTiONFEE T_,_ _. S SU&IEGTTOTHEWORKE.RS'COMPENSATIONVEiOVI51�NSOFSECTION9]OOOFTHELABOR �SSUANCE � � ,__ __, �� CADE,ISNALLFOFlTMWITHCqMPLVWI7H H�SEPROVISIONS �� o 'n �Q � -�—=- �---�� ��-- p� DATE:�=W^�APPLIGANL� SMIP .___ _.____,__p�.f�.._ � .WAflNING',FAILURETOSECIIHEWONKEFS'COMPENSATIONCOVEflAGEISUNLAWFl1LAND5HAlL0E ENERGYP/C „ ,___ __ � -_., ._____ � SV9JECTANEMPLOYERTOCRIMiNALPENALTIESANDCIVILFINESUPTOONEHUNbqEDTHOUSANU ENERGYPERMIT � _.. DOI,LAAS(51ao.OW),INADDITIONTOTHECOSTOFCOMPENSATION,OAMAGESpSPROVIUEOF�RIN '--" "-- --"—""-- '-"' — � SECTION3]090FTHELABOflCODE,INTE1iEST,ANDATTORN[V'SFEE3. RETENTIONFEE: _._ __ -.___ . _ _.__._ -._ � CONSTRUC710NLENDINGAGENCY PRE-ALTFEE: _,.__,__ ___. __.___._-... .._ O � IHEREBVAFFIqMUNDERPEYALTYOF7EflJUFYTHATTNEREI5ACONSTRUCTIONLENDINGNGENGY ___ ___ ,__,_ FOR THF PERFORMANCE OF THE WORK FOH WHIGH 7HI5 PERMIT IS ISSUEO(SEG.3097,CIV.C.�. � _-' _.- _. '. _ � LEN�ER'SNAME____ _-'__ "___ ' __ .._-"_ "'-"' ' -' -'- M� LF.NDER'SADDflESS _�-_.----- .-.-�- j� wICEFTIFYTHATIHAVEREAUTHISAPPLICATIONAN�STATETHATTHEA80VEWFOHMnTIONISCORFECT. TOTAL FEES '"` � � IAGREETOCOMPLYWITHPLLCI7YANDCWNTYOP�INANCESANDSTA'fEUWSRELATINGTO8V14DING �� e��� CONSTRUCTION,ANU HEREBYAUTHORIZE REPRESENTATNf:S OF 7HI5 COUNTV 70 ENTEq 4PON THE ZABOVE�MENTIONF.D PflOPEPTY FORINSPECTION PU�POSES. COMMENTS___ ____.. __ -_ .__ � .���-��-�- --- ---- - m PEflMITTE (PRINT) � � -. �_" "- ' '--- (n d � �r�� � __'__—__ _ � SIGINi�W���EIA1R1 DATE � _ . 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